1. Name of Firm:
2. Local Address: National Headquarters:
3. Local Telephone Number(s), Toll-Free Number(s)
4. Primary Representative/Manager/Partner-in/Charge:
Name Name
Title Title
5. Is the firm a Primary Dealer in U.S. Government Securities, as designated by the Federal Reserve of New York, qualifying under S.E.C. Uniform Net Capital Rule 15c3-1?
Yes No
If yes, for how long has the firm been a Primary Dealer? years
6. Is the firm a commercial bank chartered under laws of 1 of the United States?
Yes Chartered under laws of the State of:
No
If yes, are the bank customers' deposits insured by the Federal Deposit Insurance Corporation?
Yes No
7. Is the firm licensed to sell securities in the State of Ohio?
Yes No
8. Is/Are the person(s) designated to service the City's account licensed to sell securities in the State of Ohio?
Yes No
9. Is the firm a member of the Federal Reserve System?
Yes No
10. What was the firm's approximate total retail volume in U.S. Treasury and Agency securities last year?
Firmwide $ Number of Transactions
Local Office $ Number of Transactions
11. Identify personnel who will be trading with or quoting prices of securities to our government:
Name Title
Name Title
12. Please identify the firm's most directly comparable public sector clients in our geographical area:
Entity: Contact Person:
Telephone No. Client since
Entity: Contact Person:
Telephone No. Client since
13. Have any of your public sector clients ever reported to the firm, its officers or employees, that they sustained a loss (in a single year) exceeding 10% of original purchase price on any individual security purchased through the firm?
Explain
14. Has the firm ever been subject to a regulatory or state/federal agency investigation for alleged improper, fraudulent, disreputable, or unfair activities related to the sale of securities?
Yes No
15. Who audits the fiduciary systems of the firm's custody and delivery processes?
16. Has the firm consistently complied with the Federal Reserve's Capital Adequacy Standard?
Yes No
17. By what factor (1.5x, 2x, etc.) does the firm presently exceed the Capital Adequacy Standard's measure of risk?
18. Has the firm's capital position ever fallen short of the Capital Adequacy Standard?
Yes No
19. What portfolio information do you require from your clients?
20. What reports, confirmations, documents and audit trail will we receive?
21. Approximately how many and what percentage of the firm's transactions failed last month?
Transactions %
Last Year?
Transactions %
22. Describe the precautions taken by the firm to protect the interest of the public when dealing with governmental agencies as investors:
23. Please supply the following:
A. The firm's most recent audited annual financial report and most recent quarterly report.
B. Proof of the firm's designation by the Federal Reserve Bank of New York as a “primary securities dealer"
- OR -
Proof of FDIC coverage.
C. Proof of individual's (assigned to service the City's account) State of Ohio securities sales license.
D. Proof of the firm's State of Ohio securities sales license.
CERTIFICATION
I hereby certify that I have personally read the investment policies and objectives of the City of Tipp City, Ohio, and have implemented reasonable procedures and a system of controls designed to preclude imprudent investment activities arising out of transactions conducted between our firm and the City of Tipp City, Ohio. Sales personnel assigned to service the City of Tipp City's account(s) will be informed of the investment objectives, horizon, outlook, strategies, and risk constraints whenever we (the firm) are so advised. We pledge to exercise due diligence in informing you of all foreseeable risks associated with financial transactions conducted with our firm. I attest to the accuracy of our responses to the questionnaire.
Signed
Date Title
(1974 Code, Chapter 39, Appendix A) (Ord. 9-94, passed 5-2-1994)